Nodal management and upstaging of disease: initial results from the Italian VATS Lobectomy Registry

Abstract

Background: VATS lobectomy is an established option for the treatment of early-stage NSCLC.Complete lymph node dissection (CD), systematic sampling (SS) or resecting a specific number of lymph nodes (LNs) and stations are possible intra-operative LN management strategies.Methods: All VATS lobectomies from the "Italian VATS Group" prospective database were retrospectively reviewed. The type of surgical approach (CD or SS), number of LN resected (RN), the positive/resected LN ratio (LNR) and the number and types of positive LN stations were recorded. The rates of nodal upstaging were assessed based on different LN management strategies.Results: CD was the most frequent approach (72.3%). Nodal upstaging rates were 6.03% (N0-to-N1), 5.45% (N0-to-N2), and 0.58% (N1-to-N2). There was no difference in N1 or N2 upstaging rates between CD and SS. The number of resected nodes was correlated with both N1 (OR =1.02; CI, 1.01-1.04; P=0.03) and N2 (OR =1.02; CI, 1.01-1.05; P=0.001) upstaging. Resecting 12 nodes had the best ability to predict upstaging (6 N1 LN or 7 N2 LN). The finding of two positive LN stations best predicted N2 upstaging [area under the curve (AUC) of receiver operating characteristic (ROC) =0.98].Conclusions: Nodal upstaging (and, indirectly, the effectiveness of intra-operative nodal management) cannot be predicted based on the surgical technique (CD or SS). A quantitative assessment of intra-operative LN management may be a more appropriate and measurable approach to justify the extension of LN resection during VATS lobectomy.

Nodal Outcomes of Uniportal versus Multiportal Video-Assisted Thoracoscopic Surgery for Clinical Stage I Lung Cancer

“…According to the Cancer and Leukemia Group B prospective clinical trial (CALGB 9761), the incidence of nodal upstaging is 28% in clinical stage I lung cancer, 14% in stage II, and 14% in stage III [24]. More recently, an Italian VATS group reported nodal upstaging rates of 6.03% (N0 to N1) and 5.45% (N0 to N2) [25]. The overall incidence of nodal upstaging in our study was 8.09% (3.86% for N0 to N1, 3.13% for N0 to N1/2, and 1.11% for N0 to skip-N2 disease).…”

“…The recommended number of nodes or stations for accurate nodal staging varies among sources. Some authors have proposed that 11-14 lymph nodes or at least 5 stations be resected [25,26]. The guidelines of the European Society of Thoracic Surgeons recommend systematic MLND for all resectable lung cancer, including at least 3 N2 stations [5].…”

2016 Annual Report from the Italian VATS Group

“…Two papers have been published [9,10]. Seven abstracts have been accepted at the two European Conferences of Thoracic Surgery (European Society of Thoracic Surgeons [ESTS] and European Association of Cardio-Thoracic Surgeons), at the European Lung Cancer Conference and at the European Respiratory Society (ERS) and will be subsequently submitted as manuscripts for potential publication in their respective journals.…”

Sublobar resections for lung cancer: Finally, some answers and some more questions?

“…In the early stages of this rekindled debate, margin 2–5 and nodal status 6–8 and defining truly minimally invasive surgery 9–12 (no rib spreading) emerged as quintessential factors influential to determining the right operation for the lung cancer patient. One could almost hear the collective sigh, and with it, the certainty that once these matters were sorted, a clear winner would emerge, and the profession could move on to more pressing matters.…”